INTENSIVE IN HOME (IIH) H2012 INITIAL Service Authorization Request Form MEMBER INFORMATION PROVIDER INFORMATION Member First Name Organization Name Member Last Name Group NPI # Medicaid Number Provider Tax ID # Member Date of Birth Provider Phone Gender Choose an item. Provider E-Mail Member Plan ID # Provider Address Member Address City, State, Zip City, State, Zip Provider Fax # Parent/Guardian *Clinical Contact Name & Credentials Parent/Guardian Clinical Contact Phone Contact Information * This is the individual whom the MCO can reach out to; to answer additional clinical questions. Request for Approval of Services: From (date) To (date) for a total of units of service. Plan to provide hours of service per week. Is this a new service for the member? Yes No If no, then complete an authorization for continuing care. Primary Diagnosis Secondary Diagnosis Name of Medication Dosage Frequency Retro Review Request? Yes No If additional medications are prescribed, include listing of medications, dosage, and frequency as an attachment. SECTION I: INTENSIVE IN HOME ELIGIBILITY CRITERIA There is a parent/legal guardian or responsible adult with whom the member is living who is willing to participate in services with the goal of keeping the child with the family. The diagnosis must support the mental, behavioral or emotional illness attributed to the recent significant functional impairments in major life activities Individual must meet TWO of the following; check applicable criteria: Has difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out of home placement because of conflicts with family or community (Note: Please refer to DMAS provider manual for risk of hospitalization and out of home placement definitions/criteria). * If a child is at risk of hospitalization or an out of home placement, state the specific reason and what the out of home placement may be. Describe current symptoms and behaviors or other pertinent information which provides substantiation for CHECKED response (Identify frequency, intensity, and duration of each behavior): 1
Exhibits such inappropriate behavior that documented, repeated interventions by the mental health, social services or judicial system are or have been necessary resulting in being at risk for out of home placement. Describe current and past services/interventions which provides substantiation for CHECKED response as stated above: Provider Currently in Dates of Services/ Outcomes/Current Progress Service? Interventions Exhibits difficulty in cognitive ability such that they are unable to recognize personal danger or significantly inappropriate social behavior. Describe current symptoms and behaviors or other pertinent information which provides substantiation for CHECKED response (Identify frequency, intensity, and duration of each behavior): Individual must meet ONE of the following; check applicable criteria: Services far more intensive than outpatient clinic care are required to stabilize the individual in the family situation. Describe pertinent information which provides substantiation for CHECKED response (ex. What services have been tried and with what result, Describe severity and intensity of behaviors): The individual s residence as the setting for services is more likely to be successful than a clinic. Describe pertinent information which provides substantiation for CHECKED response. If services are going to be performed in alternative service location outside the home setting, please indicate the reason and how interventions will be integrated and generalized into the individual s primary place of residence: SECTION II: CARE COORDINATION Primary Care Physician: Other medical/behavioral health concerns (including substance abuse issues, developmental/cognitive impairments) that could impact services? If yes, explain: Please indicate other current medical/behavioral services and additional community supports interventions received: Name of service/treatment Provider/contact information Frequency Indicate plan to coordinate with primary care physician and other treatment providers/services to help ensure treatment interventions are coordinated: 2
SECTION III: TRAUMA INFORMED CARE Trauma Informed Care (Many individuals have experienced potentially traumatic events in their lifetime. It is important that everyone is aware of the potential impact of trauma on those they serve, prepare to recognize and offer trauma specific services when needed, and be mindful of trauma informed interventions.) Is there evidence to suggest this member has experienced trauma? What is your plan to assess/refer and address the current and potential effects of that trauma? SECTION IV: INDIVIDUAL TREATMENT GOALS TREATMENT GOALS: Describe person centered, recovery oriented, trauma informed mental health treatment goals as they relate to requested treatment. Include individual strengths/barriers/gaps in service, and written in own words of individual seeking treatment/or in a manner that is understood by individual seeking treatment. If individual has identified a history of trauma, please include trauma informed care interventions in the treatment plan. Services are intended to include goal directed training/interventions that will enable individuals to learn the skills necessary to achieve or maintain stability in the least restrictive environment. Providers should demonstrate efforts to assist the individual in progressing toward goals to achieve their maximum potential. Please demonstrate that the individual is benefiting from the service as evidenced by objective progress toward goals or modifications and updates that are being made to the treatment plan to address areas with lack of progress. Resources and Strengths: Document individual s strengths, preferences, extracurricular/community/social activities and people the individual identifies as supports. Please describe any barriers to treatment: How many hours each week will at least one family member be committed to participate in treatment How many hours per week of on site supervision or direct counseling/therapy by an LMHP Type will be provided: If no in home counseling/therapy is provided in the home, why, and who is providing therapy/counseling and what is the frequency? Goal/Objective (Please provide objective measures to demonstrate evidence of progress. Measurable objectives should have meaningful tracking values; avoid percentages unless able to track and measure percent completion i.e. if 80%, state 8 of 10 as a more trackable value): Please describe where the member is now regarding this specific objective. How many days per week will be spent addressing this goal on average? What specific training and interventions that will be provided to address this goal? How will you measure progress on the counseling or interventions provided? Goal/Objective (Please provide objective measures to demonstrate evidence of progress. Measurable objectives should have meaningful tracking values; avoid percentages unless able to track and measure percent completion i.e. if 80%, state 8 of 10 as a more trackable value): Please describe where the member is now regarding this specific objective. How many days per week will be spent addressing this goal on average? What specific training and interventions that will be provided to address this goal? How will you measure progress on the counseling or interventions provided? Goal/Objective (Please provide objective measures to demonstrate evidence of progress. Measurable objectives should have meaningful tracking values; avoid percentages unless able to track and measure percent completion i.e. if 80%, state 8 of 10 as a more trackable value): 3
Please describe where the member is now regarding this specific objective. How many days per week will be spent addressing this goal on average? What specific training and interventions that will be provided to address this goal? How will you measure progress on the counseling or interventions provided? SECTION V: Discharge planning DISCHARGE PLAN (Identify lower levels of care, natural supports, warm hand off, care coordination needs) STEP DOWN SERVICE/SUPPORTS IDENTIFIED PROVIDER/SUPPORTS OBJECTIVES TO ASSIST IN TRANSITION Recommended level of care at discharge: The Intensive In Home Service Specific Provider Intake has been completed by the LMHP Type and the treatment history information reviewed. It is determined that the individual meets the IIH criteria., Name of LMHP & Credentials Date 4
PLEASE SEND FORM TO THE DESIGNATED HEALTHCARE PLAN USING THE CONTACT INFORMATION BELOW FOLLOWING THE TIME FRAME REQUIREMENTS ALSO BELOW All MCOs rely on Contract Standards 3 business days or up to 5 business days if additional information is required CONTACT INFORMATION Commonwealth Coordinated Care Phone Number Fax Number (CCC) Plus Web Portal Aetna Better Health of Virginia 855 652 8249 855 661 1828 Anthem HealthKeepers Plus (800)901 0020 (for inpatient) (877) 434 7578 (for inpatient) (800) 505 1193 (for outpatient) https://www.aetnabetterhealth.com/ virginia/providers/portal https://mediproviders.anthem.com/v a/pages/precert.aspx Magellan Complete Care of Virginia (800) 424 4524 (866) 210 1523 Pending/ TBA 2018 Optima Health Community Care 1 888 946 1168 (844) 348 3719 (BH Inpatient) (844) 895 3231 (BH Outpatient) United Healthcare (877) 843 4366 (855) 368 1542 www.optimahealth.com www.providerexpress.com Virginia Premier Health Plan (844) 513 4951 (888) 237 3997 Pending/ TBA 4/1/2018 Timeframe Requirements for Submission CMHRS Services (Concurrent) (excluding CI/CS) CI/CS Aetna 7 business days 48 hrs. Anthem 14 business days 48 hrs. MCC 7 business days 48 hrs. Optima 7 business days 48 hrs. United Healthcare 14 business days 48 hrs. 5
Virginia Premier 14 business days 48 hrs. 6